PROCEDURE: Middle Meningeal Artery Embolization for SDH.
COMPARISON: None.
INDICATION: Patient with SDH
OPERATOR: Nasser Razack, M.D. J.D.
EQUIPMENT: 5F micropuncture set, 6 French short sheath, 5F Vertebral catheter, 6 Fr Benchmark Guide Catheter, .035 Bentson and .035 Terumo guidewires, rotating hemostatic valves, large bore stopcocks, Echelon 10 x 2 microcatheter, Synchro2 Soft 014/ Aristotle 018 microwire. Embolic material: Embospheres 300-500 microns in size/ Onyx 18/34 x _ vials. Angioseal 6 French vascular closure device.
CONTRAST: ml of Isovue 300/Visipaque 320
CONTROL ANGIOGRAMS: 2
RADIATION EXPOSURE-DAP: (µGy•m²)
COMPLICATIONS: None
CONSCIOUS SEDATION: Pre-procedure evaluation confirmed that the patient was an appropriate candidate for conscious sedation. Adequate sedation was maintained during the entire procedure. Vital signs, pulse oximetry, and response to verbal commands were monitored and recorded by the nurse throughout the procedure and the recovery period. The flow sheet was placed in the medical record including the medications and dosages used. No immediate sedation related complications were noted.
CONSCIOUS SEDATION: Pre-procedure evaluation confirmed that the patient was an appropriate candidate for conscious sedation. Adequate sedation was maintained during the entire procedure. Vital signs, pulse oximetry, and response to verbal commands were monitored and recorded by the nurse throughout the procedure and the recovery period. The flow sheet was placed in the medical record including the medications and dosages used. No immediate sedation related complications were noted.
GENERAL ANESTHESIA: Pre-procedure evaluation confirmed that the patient was an appropriate candidate for general anesthesia. Adequate anesthesia was maintained during the entire procedure by the anesthesia team. Vital signs and pulse oximetry were monitored and recorded by the anesthetist throughout the procedure and the recovery period. The flow sheet was placed in the medical record including the medications and dosages used. No immediate sedation related complications were noted.
CONSENT: The risks, benefits, and alternatives of the procedure were explained to the patient/patient's family and informed consent was obtained. Given the patient's condition, the patient was not able to sign their own consent. For this reason, this procedure was done emergently without consent. Risks include but are not limited to infection, bleeding, hematoma, retroperitoneal hemorrhage, vascular injury, stroke, severe stroke, contrast reaction including allergic reaction and contrast induced encephalopathy, inadvertent embolization (stroke and blindness), mucosal ulceration, skin necrosis including nasal skin necrosis and blindness. Inadvertent embolization to the eye and brain were emphasized reiterating the risk of stroke and blindness.
TIMEOUT: Prior to the start of the procedure, a time-out was performed in the presence of the Neurointerventionalist, the Nurse, and the Technologist. This identified the correct patient, site, and procedure to be performed.
PROCEDURE: The risks, benefits, and alternatives to the procedure were explained to the patient and the family, and written informed consent was obtained. The patient was placed supine on the angiographic table and the right groin was prepped and draped in the usual sterile manner. Using a 5F micropuncture set, the common femoral artery was punctured and cannulated and a 5 French arterial sheath was placed over a guidewire. The sheath was attached to continuous heparinized saline flush. A diagnostic catheter was placed through the sheath and advanced over a Terumo glidewire into the aortic arch.
Selective catheterization of the following blood vessels was performed (see below). At the end of the procedure, hemostasis was achieved.
At the end of the procedure, the sheath was removed and hemostasis was obtained with the 6 French Angioseal vascular closure device.
DIAGNOSTIC ARTERIOGRAPHY AND SUPERVISION AND INTERPRETATION OF DIAGNOSTIC ARTERIOGRAMS:
RIGHT INTERNAL CAROTID ARTERY: The catheter was then advanced into the right internal carotid artery. DSA was performed in the AP and lateral projections with filming over the intracranial circulation. Intracranial segments of the internal carotid artery are normal. Normal ophthalmic artery and choroidal blush are identified. MCA and ACA vascular territories are normal in appearance. Main intracranial venous structures opacify appropriately.
RIGHT EXTERNAL CAROTID ARTERY: The catheter was then advanced into the right external carotid artery and DSA was performed in the AP and lateral projections with filming over the intracranial circulation. The external carotid artery trunk is widely patent. The right middle meningeal artery is identified.
LEFT INTERNAL CAROTID ARTERY: The catheter was then advanced into the left internal carotid artery and DSA was performed in the AP and lateral projections with filming over the intracranial circulation. Normal ophthalmic artery and choroidal blush are noted. The MCA and ACA trunks and distal branches are within normal limits. Arteriovenous transit time is normal. Main intracranial venous structures opacify appropriately.
LEFT EXTERNAL CAROTID ARTERY: Catheter was used to select the left external carotid artery and DSA was performed in the AP and lateral projections with filming over the extracranial circulation. Main ECA trunk is widely patent. Normal external carotid artery branch pattern is appreciated. The left middle meningeal artery is identified.
SUPERSELECTIVE ARTERIOGRAPHY, EMBOLIZATION, AND CONTROL ANGIOGRAMS; SUPERVISION AND INTERPRETATION OF SUPERSELECTIVE ARTERIOGRAPHY, EMBOLIZATION, AND CONTROL ANGIOGRAMS:
EMBOLIZATION, RIGHT SIDE: The guide catheter was advanced over the diagnostic catheter into the right external carotid artery. This was attached to continuous heparinized saline flush. Through this, the echelon 10 microcatheter was advanced over the microwire into the middle meningeal artery under continuous fluoroscopic roadmap guidance.
RIGHT MIDDLE MENINGEAL ARTERY: DSA was performed in the AP and lateral working projections through the superselective microcatheter within the middle meningeal artery. Normal opacification of this arterial tree is seen. No evidence of pseudoaneurysm, aneurysm, or telangiectasia. No dangerous collaterals are identified. The microcatheter was positioned within the middle meningeal artery within the right frontal branch/proximal to the frontal and posterior branch bifurcation. From this catheter position, 0.5 mL of Onyx 18 was then injected in standard fashion under continuous fluoroscopic monitoring. Once considerable stasis was noted within this arterial vascular tree, a control angiogram was performed.
RIGHT MIDDLE MENINGEAL ARTERY POST EMBO: DSA in the AP and lateral working projections was performed through the microcatheter following embolization. This demonstrates truncation of this arterial tree without significant opacification of the distal branches. No evidence of complicating feature.
EMBOLIZATION, LEFT SIDE: The guide catheter was advanced over the diagnostic catheter was placed into the left external carotid artery. This was attached to continuous heparinized saline flush. Through this, an echelon 10 microcatheter was advanced over a Syncro2 soft 014 microwire into the left middle meningeal artery under continuous fluoroscopic roadmap guidance. DSA was then performed from this catheter position.
LEFT MIDDLE MENINGEAL ARTERY: DSA was performed in the AP and lateral working projections through the superselective microcatheter within the middle meningeal artery. Normal opacification of this arterial tree is seen. No evidence of pseudoaneurysm, aneurysm, or telangiectasia. No dangerous collaterals are identified. The microcatheter was positioned within the middle meningeal artery within the right frontal branch/proximal to the frontal and posterior branch bifurcation. From this catheter position, 0.5 mL of Onyx 18 was injected into the meningeal artery in standard fashion under continuous fluoroscopic monitoring. Once considerable stasis was noted within this arterial vascular tree, a control angiogram was performed.
LEFT MIDDLE MENINGEAL ARTERY POST EMBO: DSA in the AP and lateral projections was performed through the microcatheter following embolization. This demonstrates truncation of this arterial tree with no significant residual opacification of the distal branches. No evidence of a complicating feature.
1. Successful Onyx 18 embolization of the bilateral middle meningeal arteries.